CSF Pressure, Volume, and Post-Dural Puncture Headache: A Case-Control Study and Systematic Review

Area of Science:

• Neurology
• Anesthesiology
• Neurosurgery

Background:

• The International Classification of Headache Diagnoses, 3rd Edition (ICHD-3) criteria for post-dural puncture headache (PDPH) require documentation of intracranial hypotension, a concept yet to be definitively proven.
• Current diagnostic criteria for PDPH may need revision based on emerging evidence.

Purpose of the Study:

• To systematically review existing literature evaluating the association between PDPH and cerebrospinal fluid (CSF) opening pressure (OP), closing pressure (CP), and volume removed (V).
• To conduct a case-control study investigating the pressure-volume index (PVI) as a potential novel risk factor for PDPH.

Main Methods:

• A systematic literature review was performed across multiple databases (Cochrane, EMBASE, MEDLINE, Scopus, Web of Science).
• Studies were included if they compared headache incidence after lumbar puncture (LP) based on OP, CP, and/or V.
• A retrospective, case-control study with 1:1 matching was conducted using ICHD-3 criteria, excluding patients with factors influencing CSF pressure.

Main Results:

• The systematic review found no convincing evidence linking PDPH incidence to OP or CP.
• A minority of studies suggested an association between PDPH and V, particularly with high-volume CSF removal or when stratified by headache onset timing.
• The case-control study found no significant difference in elastance or PVI between PDPH cases and controls.

Conclusions:

• The overall risk of PDPH does not appear to be significantly influenced by OP, CP, V, or PVI.
• PDPH may be associated with V in cases of high-volume CSF removal and could depend on the timing of assessment.
• Future diagnostic criteria for PDPH should consider immediate and delayed subtypes and should not mandate intracranial hypotension.